Basic Airway Management

Open the Airway

1) Head-tilt/chin-thrust (B)
- place tips of fingers beneath pt’s chin and lift up towards ceiling. The upper neck will
naturally extend. Use the thumb to open the pt’s mouth while the neck is extended

2) Jaw-thrust manoeuvre (C)

- place middle or index fingers behind the angle of the mandible. Lift the mandible toward
the ceiling until the lower incisors are anterior to the upper incisors. This manoeuvre can
be performed in combination with the head-tilt/chin-lift maneuver or with the neck in the
neutral position during in-line stabilisation.

3) Remove foreign bodies via Heimlich manoeuvre or back-slap

Position patient

- supine position is the best for supporting the airway

- the “sniffing” position is achieved by flexion of the lower cervical spine and tilting the head
backwards
- in pts who are actively vomiting or have excessive oral bleed/secretions, left lateral
position is best

Suction oropharyngeal space

- clear secretions, vomitus and blood from oral cavity (nasal not generally required in adults)
- avoid prolonged suctioning (>15s) as it may cause hypoxia, especially in neonates.
- Give supplemental O2 between suctioning

Insert artifical airway

- oropharyngeal (Guedel airway) and nasopharyngeal airways prevent the tongue from
obstructing and falling of posterior wall of mouth
- Guedel insertion: place airway in an inverted position along hard palate. When well inside
the mouth, rotate 180 degrees and advance (D&E)
- Nasopharyngeal airways are easily placed through the nares and advanced. It may cause
epistaxis and care needed in facial fractures

Give Oxygen
 - if attempting to intubate patient, pre-oxygenation will be required (100% O2 delivered via
face-mask for 2 – 5 minutes)
- if pt is apnoeic you will have to assist with ventilation by bag & mask (see LO)

Bag-Mask Ventilation

Positioning
- mask must be adequate for size of patient’s face to get a tight
seal
- pt should be in a supine position with head and neck tilted back in
a “sniffing” position, which allows the base of the tongue and
epiglottis to be pulled anteriorly
- Using the thumb and 1st finger apply pressure to the mask which concurrently using the 2nd
and 3rd fingers to displace the mandible upwards. The 5th finger should hook around the
angle of the jaw.

Technique
- peak airway pressures must remain lower than 20cm H20
to prevent stomach inflation
- squeeze the bag slowly and not to maximum capacity –
approximately 500ml should be delivered over 1-1.5
seconds (In a 2.5L bag it’s only a very small amount, so it’s
easy to over-ventilate) at a rate of approximately 15
breaths per minute
- Bag-mask device should be attached to a supplemental O2
source with a flow rate of 15L/min to avoid hypoxia
- Judge effective oxygenation and ventilation by chest rise,
breath sounds, O2 sats and exhaled CO2 monitoring.

Risk factors for difficult bag & mask ventilation

 Presence of a beard
 BMI >26 kg/m2
 Lack of teeth
 Age >55yrs
 History of snoring

- In these pts a poor mask seal leads to higher airway pressures and increased risk of gastric
insufflation and aspiration
- To lessen gastric dilatation Sellick’s Maneuver may be used, but applying cricoid
pressure during bag-mask ventilation. This pushes the trachea posteriorly and compresses
the oesophagus against the cervical vertebrae. It should be used in all resuscitations and
rapid sequence inductions for anaesthesia (RSIs).
- leaving well-fitting dentures in will assist in ventilating
- during CPR use a two-person approach to bag-mask ventilation